It's a good thing Americans' opinions about healthcare aren't symptoms of an illness. If they were, we'd see a lot of perplexed professionals in white lab coats hovering over the body politic as they tried to wring a diagnosis out of all the mutually contradictory indications. Consumers have lots of opinions -- about their own care and about the condition of healthcare in the country at large -- and these don't all fit together very neatly. The resulting complexity poses a challenge for advocacy-group advertisers and other players in the struggle over healthcare reform as the legislative debate in Washington comes to a head.

When people are asked about the general state of the current, unreformed American healthcare system, their opinions are resoundingly negative. A CBS News/New York Times poll last month was typical in its finding that 34 percent of respondents believe the system is so bad that "we need to completely rebuild it," with another 51 percent saying the system needs "fundamental changes." Nor has the bad economy defused a sense of urgency about the matter. Kaiser Family Foundation polling last month found 61 percent of its respondents agreeing that "It is more important than ever to take on healthcare reform now."

If people had similarly dire opinions of their own healthcare and coverage, they'd be storming the Capitol to demand immediate enactment of reform. But here's where things start to get complicated: A conspicuous feature of public opinion about healthcare is that large majorities of Americans describe themselves as content with their own healthcare arrangements. A sampling of polling results from last month tells this story. The CBS News/New York Times survey found 77 percent of respondents satisfied (including 47 percent "very" satisfied) "with the quality of the healthcare you receive." Focusing specifically on "your health insurance coverage," an ABC News/Washington Post poll found 42 percent of insured respondents "very satisfied" with it, plus another 39 percent "somewhat satisfied." Asking respondents to perform a bit of cost/benefit analysis, a Quinnipiac University poll found 70 percent agreeing that they personally "get good value for the money you spend on healthcare."

ABC News's report of its findings included this analysis of the opinion landscape: "The chief obstacle to reform is that large majorities are satisfied with their current care and coverage; most, albeit fewer, also call their costs tolerable. Dissatisfaction with the system overall, and worry about future costs, are countered by broad concerns that change could worsen the quality, choice and coverage most Americans enjoy now."

This satisfaction many people feel with their personal-healthcare status quo provides a potential opening for opponents of wholescale reform. "People are risk-averse in their own arrangements," says Mollyann Brodie, vp, director of public opinion and survey research at the Kaiser Family Foundation. "It's easy to scare people into thinking the status quo is the best option for their family, even if they think it's not the best for other people or for the nation."
 
No doubt a lot of viewers will be scared by a commercial aired by Patients United Now, a project of the Americans for Prosperity Foundation, that opposes the Democratic reform proposals. It features a Canadian woman who tells us she would have died of her brain tumor, due to delays in care, if she'd had to rely on her Canadian national healthcare coverage. She's alive only because she was able to travel to the U.S. for care. "Now," says a voiceover, "Washington wants to bring Canadian-style healthcare to the U.S. But government should never come between your family and your doctor." A key aim of the commercial, says Amy Menefee, policy advisor and national spokesperson for Patients United Now, is to rebut the pro-reform claim that people will be able to keep their current healthcare arrangements under the new system. "It's always tough for people to envision that a new policy would affect their lives on a real, daily basis," she says. "But this brand of healthcare reform definitely would do just that. Analysis after analysis of the plans coming out shows that President Obama's promise that 'if you like your plan, you can keep it' is unrealistic."

There certainly is anxiety among consumers that reform could have adverse effects on them personally. In the CBS News/New York Times poll, 28 percent were very concerned and 35 percent somewhat concerned that their own care would get worse if the government "creates a system of providing healthcare for all Americans." Similarly, the ABC News/Washington Post poll fond 58 percent believing that healthcare reform "will require everyone to make changes, whether they want to or not." These are the sort of widely held opinions that lead the Kaiser Family Foundation's Brodie to remark, "The anti-reform side, I'd say unequivocally, has it easier" when it comes to pushing public opinion in a given direction.



But while a majority of Americans may be happy with the coverage and care they now have, this doesn't mean they're confident about hanging onto it and being able to afford it -- regardless of what Washington does or does not do. For example, 49 percent of the CBS News/New York Times respondents said they're "very concerned" (with another 37 percent "somewhat concerned") about "the healthcare costs you and your family might face in the coming years." And many have already seen changes for the worse: 44 percent said their employer or the employer of someone else in their household has "in recent years" cut back on healthcare benefits or made the employee pay more for them. And amid the general satisfaction people express about their care and coverage, many have already been forgoing needed care because of its cost. In the Kaiser survey, a stunning 55 percent reported that someone in their household had put off getting some needed care in the past 12 months due to cost.

Worries of this sort make people less attached than they'd otherwise be to the status quo. And so does the antipathy they feel toward some segments of the healthcare system. Polling last month by Resurgent Republic, a right-leaning research-cum-advocacy group that opposes the Democratic reform proposals, found 55 percent of respondents agreeing that "greedy insurance companies and drug companies" charge "way too much for the services they provide."

Those people will likely lend a receptive ear to a commercial by pro-reform organization Health Care for America Now that takes aim at insurance companies. "What if we stripped away the $13 billion insurance company profits, the $119 million CEO bonuses," begins the voiceover -- "the endless denials [of coverage], the soaring co-pays and premiums. You'd have healthcare between you and your doctor. That's the president's plan." The spot goes on to promote a government health-insurance option as a way to "lower costs and keep insurance companies honest" -- the plain implication being that insurance companies aren't especially good at keeping themselves honest.

The spot includes reassurance that you can keep your current healthcare arrangement under the president's reform plan, but the emotional energy at the beginning of the spot comes from the slap at insurers. Why this approach? "The reason the spot works is that it plays off the incredible frustration people have with the insurance industry," says Richard Kirsch, national campaign manager for Health Care for America Now. "Ads that play off people's anger with the insurance industry are by far the most effective," he says of his organization's own research on the matter. "People are worried about losing what they have, but they're also frustrated with the delays and the denials."

Kirsch also feels that this widespread sentiment tends to blunt the effectiveness of messages the anti-reform side is using. Noting that both sides have run commercials showing patients with their doctors, he says of the anti-reformers, "Their frame is, 'The government is going to wreck that relationship.' Our frame is, 'The insurance industry already wrecked it.'" Given the experience people have had with insurers, he says there's less resonance to the "anti-government fear-mongering" that was successful in 1993 when the Clinton administration's healthcare plan was on the table. Having had to deal with "insurance-industry bureaucrats" in the intervening years, people are less apt to be frightened by the notion of "government bureaucrats" intruding on their care, says Kirsch.

In promoting a government-run health insurance plan as one of the options that should be available to consumers, the Health Care for America Now commercial touches on what is emerging as one of the major points of contention in the healthcare-reform debate. Those in favor say it will give consumers one more option and compel private-sector insurance companies to be reasonable in their pricing. Opponents say such a "public option" insurer, with the government behind it, would inevitably drive private insurers out of business and have the consequence (whether intended or not) of pushing everyone into a government-run plan. As with so many aspects of the healthcare-reform issue, public opinion on this matter depends partly on the way the question is framed. In the Quinnipiac poll, respondents by a wide margin (69 percent vs. 26 percent) favored "giving people the option of being covered by a government health-insurance plan that would compete with private plans," even though just 28 percent said they themselves would buy from the government. Likewise, 62 percent of respondents in the ABC News/Washington Post poll said they support having the government "create a new health-insurance plan to compete with private health-insurance plans." But when this poll raised the possibility that such an entity could put most private insurers out of business, support fell to just 37 percent.



Blue Cross and Blue Shield of North Carolina has waded into the debate with material on its Web site (including a video featuring the CEO, Bob Greczyn) explaining that while the company supports healthcare reform, it believes "government-run health insurance could be a barrier to meaningful reform." Given the increasing intensity of feeling around the whole topic of healthcare reform, is it possible to get across that you're in favor of reform while opposing a particular element of it? "Yes, this is challenging," says company spokesman Lew Borman. "The public debate is passionate, and there are some who choose to mischaracterize our Web site information." But he notes that the company does support reform and universal coverage. "We support health reform and we think the best approach is to build on the system that works for more than 160 million Americans today, rather than simply start over," Borman says.
 
Whether reform, if enacted, means starting over "simply" or otherwise, there are some elements of it that enjoy broad support. Among these is a provision that prevents insurance companies from denying coverage to people due to a pre-existing condition. In the CBS News/New York Times poll, for instance, 75 percent said they were in favor of such a rule -- with 56 percent still in favor even if it meant their own insurance costs would rise as a result.

Cost, though, is a topic where opinion tends to shift rapidly when a price tag is applied. One of the great yet-to-be-answered questions in the healthcare debate is whether people will be willing to pay higher taxes for the sake of extending coverage to people who now are uninsured. In the CBS News/New York Times poll, 57 percent of respondents said they'd be willing to pay higher taxes "so that all Americans have health insurance they can't lose, no matter what." But the "willing" vote fell to 43 percent when people were asked whether they'd be game "to pay as much as $500 a year or more in taxes" for this purpose.

If healthcare reform is funded in part by reductions in the payments the government provides to hospitals for care of people covered by Medicare and other governmental programs, this will put additional pressure on hospitals to bring in privately insured patients who'll be paying full price. As such, expect to see more hospital advertising aimed at such paying customers. "I think you're going to start seeing more messaging to different kinds of patients," just as BMW and Chevy aim at different customers, says J.D. Norman, evp, managing director at Winsper & Co., a Boston-based agency whose clients include Exeter Hospital of New Hampshire. He predicts there will be more emphasis on service and aspects of the hospital experience other than the clinical outcome. "You'll see ads saying, 'This is where you have to come for the healthcare experience you want -- not just the clinical outcome -- and you're gonna have to pay a little more for it," Norman says.

Americans are split, meanwhile, over whether cost control should have priority in healthcare reform over expansion of coverage. In NBC News/Wall Street Journal polling last month, 43 percent of respondents said the president and Congress should be most focused on expanding coverage, while 41 percent said they should concentrate more on the cost of care. By contrast, "controlling the cost of healthcare" beat "expanding coverage for Americans without health insurance" by 49 percent to 35 percent in Diageo/The Hotline polling the same month. That's roughly in sync with the Quinnipiac findings on this issue, where 54 percent said the primary goal of reform should be to lower costs and 38 percent said it should be to provide coverage for everyone.